Visual Loss in Biostimulator Injectables: A Review of Incidence, Risk Factors, Etiology and Management Proposal

Area of Science:

• Medical Aesthetics
• Ophthalmology
• Dermatology

Background:

• Non-hyaluronic acid (HA) injectables, particularly biostimulators, are increasingly popular in medical aesthetics.
• This rise in popularity has been accompanied by an increase in reported complications, including iatrogenic visual loss due to vascular occlusion.

Purpose of the Study:

• To systematically review the literature on visual loss associated with widely used biostimulator injectables.
• To report the incidence of visual loss events related to calcium hydroxylapatite (CaHA), polycaprolactone (PCL), poly-L-lactic acid (PLLA), and poly-D,L-lactic acid (PDLLA).
• To outline evidence-based management protocols for these complications.

Main Methods:

• Systematic literature review of visual loss cases linked to CaHA, PCL, PLLA, and PDLLA injectables.
• Analysis of reported incidences and anatomical locations of vascular occlusions.
• Development of a management protocol based on current evidence.

Main Results:

• Calcium hydroxylapatite (CaHA) has at least 11 reported cases of visual impairment from vascular occlusion, often involving the nasal dorsum.
• Poly-L-lactic acid (PLLA) has two confirmed reports of visual loss (periorbital/nasal and temple injections).
• Poly-D,L-lactic acid (PDLLA)-carboxy-methylcellulose (CMC) and PDLLA-hyaluronic acid (HA) have reported cases of visual loss, including posterior ischemic optic neuropathy (PION). Polycaprolactone (PCL) has one reported facial artery embolism case, with no published blindness.

Conclusions:

• A comprehensive understanding of anatomy and injectable properties is essential for preventing and managing visual loss.
• Timely recognition of symptoms, immediate interventions (intraocular pressure reduction, ophthalmologist referral), and supportive therapies are critical.
• This review provides timely guidance for physicians managing vascular occlusion complications from biostimulator injectables in aesthetic practice.